Tonsils: in or out?

Are children with inflamed tonsils likely to keep them these days?

Among children with frequent recurrences of tonsillitis, those who undergo tonsillectomy have a better quality of life compared with those who don’t. Photograph: iStockphoto

Among children with frequent recurrences of tonsillitis, those who undergo tonsillectomy have a better quality of life compared with those who don’t. Photograph: iStockphoto

 

‘Git yer tonsils out, Geordie,” chorused my primary school chums. “Ya git ice-cream, so ya do.” Throat-cooling scoops of vanilla had secured their endorsement of an operation so widespread in 1960s Belfast that I’m lucky to have avoided it.

Yet in 1938, Dr James Alison Glover of the British Ministry of Health cited a Medical Research Council report warning: “one cannot avoid the conclusion that there is a tendency for [tonsillectomies] to be performed as a routine prophylactic ritual for no particular reason and with no particular result”.

So in today’s Ireland are children with inflamed tonsils likely to keep them? A 2013 consultation document from the Health Information and Quality Authority shows that in 2011 about 3,500 tonsillectomies were undertaken here, 27 per cent fewer than in 2005.

Against a background, where the benefit of tonsillectomy is keenly debated both in the UK and Ireland, it’s notable that in 2014 the Health Service Executive (HSE) aimed to save €200 million by performing 28,000 fewer operations.

I learned this from a recently published study led by ENT surgeon Gerard Thong of University College Hospital, Galway.

Quality of life

Thong’s team, writing in the Irish Journal of Medical Science, reported that among children with frequent recurrences of tonsillitis, those who undergo tonsillectomy have a better quality of life compared with those who don’t.

“We have to be careful that healthcare ‘efficiencies’ do not lead to limited access to vital treatments and increased patient suffering as a consequence,” Thong says.

“In the UK, trials used to propose cuts in NHS tonsillectomies found ‘little benefit’, yet the overwhelming message from parents who participated in this study was that it was the best thing that they ever did.”

In the first research of its kind from an Irish population, 86 children with tonsillitis were divided into two groups: 55 undergoing tonsillectomy (with the mean age five years) and 31 controls (mean age six years) on the waiting list.

“Our study showed that even when compared with watchful waiting, tonsillectomy improved the quality of life of these children,” says Thong. “Parents reported that their child’s symptoms of infection, pain and sleep disturbance virtually disappeared following the surgery.”

Tonsillectomies, he says, were performed only on those children who satisfied international best practice guidelines.

“Not every child who suffers from tonsillitis would benefit from tonsillectomy, so parents should consult their general practitioner if they have any questions,” he says.

Clinical benefit

The authors consider tonsillectomy “to be a procedure of considerable clinical benefit and, therefore, a worthwhile allocation of healthcare expenditure”.

Perhaps against the grain of the HSE’s drive to perform fewer operations, Thong’s findings suggest that children’s tonsillectomies may not be unnecessary operations.

Talking of unnecessary operations, the Gill Committee of 2004/2005 recommended to the Minister for Health and Children that “[C]ultural male circumcision should be provided in the Irish health service.” This invites the inference that a child’s right to bodily integrity is less important than a parent’s right to adhere to their cultural belief and involve their children in these practices.

Ritual scarification and body piercings hold religious and cultural significance too, but these aren’t provided by the Irish health service.

Meanwhile, the HSE’s website acknowledges that “the risks associated with routine circumcision, such as infection and excessive bleeding, far outweigh any potential benefits”.

Yes, Article 9 (1) of the European Convention on Human Rights declares: “Everyone has the right to freedom of thought, conscience and religion.”

But Article 5 (1) states: “Everyone has the right to liberty and security of the person.” If parents ignore their child’s right to preserve his physical integrity, it’s wrong. Why not wait until they’re old enough to decide for themselves? Perhaps it’s because many young males might consider genital mutilation unappealing.

At the 1993 UN International Human Rights Conference in Vienna it was declared that human rights are universal and not determined by culture or economics, yet “[C]ultural male circumcision should be provided in the Irish health service.”

But hang on; cultural female circumcision – or female genital mutilation (FGM) – is outlawed, with UN Secretary-General Ban Ki-Moon predicting on the International Day of Zero Tolerance for FGM on February 6th, 2014, that by 2030 about 86 million young girls will have experienced its physical and mental trauma.

Unnecessary operations

Although FGM is properly considered a crime, many cosmetic surgeons undertake wholly unnecessary operations during which they effectively mutilate their patients while shaping so-called “designer vaginas”.

But, as Marge Berer, editor of the journal Reproductive Health Matters, highlighted in a letter to the British Medical Journal (June, 30th, 2007, page 1335), female genital reshaping, entailing “the partial or total removal of the external genital organs for cultural or other non-therapeutic reasons” is a criminal offence in the UK under the Female Genital Mutilation Act.

In the debate over unnecessary surgical operations, the arguments around tonsillectomy are grounded in medicine; those around genital mutilation are grounded in culture, religion and fashion, an altogether different area not exclusively patrolled by the medical profession.

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